Waffle on PSC
The specimen has an adequate length but contains only six complete portal tracts. There is mild periductal fibrosis (with a suggestion of an onion skin-like arrangement in one portal tract), mild periportal intrahepatocyte copper deposition, focal bile ductular proliferation, focal bile duct lymphocytic infiltration, and bile duct cell anisonucleosis. There is disruption of the hepatocyte plates and hepatocyte anisonucleosis, suggestive of a hepatocellular injury; however, there is no frank hepatocyte necrosis and the plate thickness is within normal limits.
There is no cholestasis, interface hepatitis, or portal or lobular inflammatory infiltrate. The PAS, PAS-D and Shikata stains are non-contributory. There is no fatty change of hepatocytes. The portal tracts have an irregular outline focally and occasional delicate periportal fibrous septae (Laennec fibrosis Stage I/IV).
Liver, core biopsy - Focal bile duct abnormalities without cholestasis and no significant inflammation, see comment.
The bile ducts have focal non-specific abnormalities without cholestasis that are not sufficient to diagnose primary sclerosing cholangitis (PSC). It is possible that this represents PSC, which is often patchy, and may have not been sampled in the relatively small number of portal tracts present in this biopsy. The histomorphologic findings are not compatible with autoimmune hepatitis.
Fulimant liver failure
A. Liver: The sections show a parenchymal lymphocytic infiltrate with massive hepatocyte necrosis and a vigorous histocytic response, as demonstrated by CD68 immunostaining. The rare surviving hepatocytes show degenerative changes or swelling. There is no definite steatosis. There are no histomorphologically normal hepatocytes. There is focal perservation of the portal tracts. The remaining central veins show fibrinoid necrosis. There is a relative preservation of the bile ducts and bile ductular proliferation, as demonstrated by pan-keratin immunostainging. There is moderate cholestasis. The parencyhma has moderate thin strands of fibrotic tissue without an apparent zonality.
Gallbladder: The section shows a normal gallbladder wall. There is no inflammation or necrosis.
i) Native liver, liver transplantation - diffuse massive hepatic necrosis, see comment.
ii) Native gallbladder, liver transplantation - no pathologic diagnosis.
The findings of massive parenchymal collapse and abundant lymphocytes, with a moderate non-zonal reactive fibrosis and a reactive bile ductular proliferation, are consistent with a viral hepatitis.